Dental Health and the Rest of the Body

The mouth is usually treated as separate from the rest of medicine, with its own practitioners, its own insurance, and its own waiting rooms. The body does not observe the distinction. Nearly half of American adults over 30 have some degree of periodontal disease, and the evidence that it interacts with the rest of health has grown steadily for two decades.

What gum disease is

Plaque, a film of bacteria, forms on teeth constantly. Left along the gum line for more than a day or two, it inflames the gum: gingivitis, which shows as redness and bleeding on brushing. Gingivitis is reversible with cleaning. If it persists, the inflammation moves below the gum line, the bone supporting the tooth begins to erode, and pockets form where bacteria thrive. That is periodontitis. It is the leading cause of tooth loss in adults and it is mostly silent until it is advanced.

The signature early sign is bleeding when you brush or floss. Bleeding is not normal and it is not a reason to brush less. It is the gum reporting inflammation.

The links to the rest of the body

Diabetes. The relationship runs both ways and is the best established. High blood sugar weakens the response to infection and makes gum disease worse. Gum disease raises inflammation and makes blood sugar harder to control. Treating periodontitis lowers A1C by about 0.3 to 0.4 points in trials, a modest but real effect. People with diabetes are advised to have dental checks at least twice a year.

Heart disease. People with periodontitis have higher rates of heart attack and stroke. The proposed mechanism is chronic inflammation and bacteria entering the bloodstream. Whether treating gum disease reduces cardiovascular events has not been shown in trials, and the two conditions share causes such as smoking and diabetes. The American Heart Association's position is that the association is real, causation is unproven, and good oral health is worth having regardless.

Pregnancy. Periodontitis is associated with preterm birth and low birth weight. Treatment during pregnancy is safe and is recommended, though trials have not consistently shown it changes birth outcomes.

Pneumonia. In older adults and in hospital patients, bacteria from the mouth are a common source of aspiration pneumonia. Oral care programs in nursing homes reduce it.

Cognitive decline. Several studies link periodontitis and tooth loss to dementia. The evidence is observational and early.

The habit that prevents most of it

Brush twice a day for two minutes with fluoride toothpaste. Clean between the teeth once a day. That is nearly the whole of prevention, and most people do the first half and skip the second.

Some details that matter:

• Electric brushes with an oscillating head remove somewhat more plaque than manual brushes in trials and reduce gingivitis a little more. A manual brush used well for two minutes is fine.
• Technique matters more than force. Angle the bristles toward the gum line at about 45 degrees and use short strokes. Hard scrubbing wears enamel and gums.
• Do not rinse after brushing. Spit, but leave the fluoride on the teeth. Rinsing with water washes it away.
• Interdental cleaning. Floss works. Small interdental brushes work better for most adults with any gap between teeth and are easier to use. Water flossers help people who will not use either. The one that gets used is the right one.
• Fluoride. It is the reason cavity rates fell by half in the second half of the 20th century. Toothpaste should contain it, and fluoridated water reduces decay in every age group.

Sugar and acid

Cavities are caused by bacteria fermenting sugar into acid, which dissolves enamel. Frequency matters more than quantity: sipping a sweet drink over an hour bathes the teeth in acid repeatedly, while the same drink finished in five minutes does less harm. Acidic drinks, including diet soda and sparkling water with citrus, erode enamel directly. Limit sweet and acidic drinks to mealtimes, and do not brush within 30 minutes of an acidic drink, because softened enamel brushes away. Ribbon Checkup's nutrition label guide covers finding the added sugar that drives most of this.

What a checkup should include

Most adults benefit from a dental visit every six to twelve months; the interval depends on risk, and someone with healthy gums and no cavities in years can go longer. A proper visit includes an examination of every tooth, a check of gum pocket depths with a probe (the numbers called out are millimeters; 1 to 3 is healthy, 4 and above is a pocket), a look at the soft tissues of the mouth for oral cancer, and X rays at intervals of one to three years depending on risk. A cleaning removes the hardened plaque that brushing cannot.

When to go sooner

Bleeding gums that do not stop within two weeks of better cleaning. Persistent bad breath. A loose adult tooth. Gums pulling back from teeth. Pain, swelling, or a sore in the mouth that does not heal in two weeks. Tooth sensitivity that is new. None of these improve by waiting, and the early version of each is far cheaper to treat than the late one.